Cancer. A word as frightening as death. National and international public health agencies are rightly concerned about it. But we push it out of our minds. We deny its presence. Men more so than women. That’s how we are programmed. So, Tingasiga, I must talk to you about one type of cancer today, to which all men are at risk. Do not worry. This is not a complicated letter in medicalese, the gibberish language that doctors use in their world.
Prostate cancer is the most common cancer in men in 112 countries, and the second most common cause of cancer deaths in men worldwide. About 1,000 Ugandan men are diagnosed with prostate cancer every year. This is likely to be an underestimate, for it reflects only those who are seen at the Uganda Cancer Institute in Kampala and its few regional satellite centres. The numbers are increasing.
Dr. Judith Asaasira and her colleagues published an important study in 2022 in which they projected an increase of prostate cancer cases in Uganda from 41.6 per 100,000 men in 2015 to 60.6 per 1000,000 men in 2030. The Lancet Commission warned us last week that we may see a doubling of worldwide prostate cancer cases to 2.9 million per year, with 700,000 deaths per year by the year 2040. This increase, which is already evident in high income countries, will accelerate in middle- and low-income countries.
This is not surprising. Prostate cancer is an age-related disease. We are living longer, giving this age-related disease an opportunity to develop. The risk increases after the age of 40 years and accelerates after the age of 50 years.
Of course, a family history of prostate cancer is a major risk factor. We cannot control or escape from that now. On the other hand, our modern lifestyle choices are avoidable risk factors. These include sedentary living, unhealthy eating habits, especially those red meats and sugary drinks that contribute to a high body mass index, tobacco and alcohol consumption, and exposure to ionizing/ultraviolet radiation.
The prostate is a tiny gland made up of five lobes that are very close to each other, creating the shape of an inverted cone. It sits below the urinary bladder, in front of the rectum. It produces fluid that, among other functions, protects sperm from the hostile effects of the acidic vaginal environment. The urethra, that tube through which urine and sperms must flow, passes through the prostate. So do two ejaculatory ducts, through which sperms and other important reproductive fluids pass on their way to the outside world.
There are three main reasons why the prostate gland may trigger a visit to your doctor. First, a painful inflammation usually caused by an infection. Second, non-cancerous enlargement of the prostate gland that can be a nuisance, including causing frequent urination, or failure to urinate. Though very important, these two conditions are not my main message today.
The third reason that demands regular visits to the doctor is surveillance for, detection of, and management of prostate cancer. All men aged 40 years and above should regularly visit their doctors to talk about their urinary health and, for the sexually active, their ejaculatory health.
The good news is that about 85 percent of men with prostate cancer have a slow growing type that usually does not cause problems. However, about 15 percent of those with prostate cancer develop an aggressive type that has the potential to cause complications and death. It requires early diagnosis and treatment by experienced cancer doctors.
Unfortunately, many patients present late for diagnosis and treatment. Some ignore or deny the symptoms because of fear of the word “cancer.” Others try ineffective herbal remedies before seeing a competent doctor. Many men lack access to a doctor, or they cannot afford the cost of evaluation and treatment. A few entrust their lives to self-styled pastors, apostles and prophets who claim to perform miracles. We are not aware of any evidence-based reports of cancer cures through prayers alone. Whatever the reason, delayed diagnosis results in an increased risk of cancer spread to other parts of the body.
Some of the symptoms that warrant immediate evaluation by a competent doctor include pain “down there”, increased frequency of urination, difficult and/or painful urination, increased urination at night, blood in the urine, painful ejaculation, blood in the ejaculated fluid, erectile dysfunction, and unexplained back, hip, or chest pain. The presence of these and other symptoms does not mean you have cancer, but they require attention. A person with advanced prostate cancer may have significant weight loss, pain in the bones, swelling of the feet and legs, blood clots, enlarged glands in the groins and inside the tummy, severe constipation because of obstruction to the large intestine, overdistended urinary bladder, nerve dysfunction. The goal of good health care is to prevent such late presentation to the doctor.
After a thorough history, the doctor will examine the patient. In resource-limited countries like Uganda, the examination always includes digital rectal examination (DRE), which means inserting a gloved, lubricated finger into the rectum, to feel the prostate gland. It is usually not painful, and it is not as uncomfortable as one might imagine it to be. In resource-rich countries, use of high-quality magnetic resonance Imaging (MRI) may enable DRE (finger examination) to be omitted.
The doctor will then request tests to establish diagnosis, before giving advice on the next course of action. One of the most common tests is measurement of prostate-specific antigen (PSA) in a sample of blood. The use of this test is controversial. Its interpretation requires careful thought by an experienced doctor using current knowledge about it. Its reliability is uncertain, and recent research suggests that it may cause overdiagnosis of prostate cancer. A new study out of the United Kingdom has suggested that PSA appears to be naturally higher in males of African ancestry. This might explain the higher rate of diagnosis of prostate cancer in males of African ancestry. New standardised, rationalised, evidence-based indications for PSA testing need to be agreed in all countries, including Uganda. Medical knowledge is always evolving. Other blood tests are under investigation. We may get new tools for early diagnosis. Wise is he who asks his doctors questions and seeks the most up-to-date information about tests and treatments.
Where digital rectal examination and PSA value suggests possible prostate cancer, magnetic resonance imaging (MRI) is recommended. If the MRI suggests clinically significant prostate cancer, a prostate biopsy, where tissue is taken from the gland for examination looking for cancer cells, should be done. Whereas this is the gold standard for establishing the diagnosis, false negative results often occur. Therefore, multiple biopsies may be required before the cancer is detected.
The Uganda Cancer Institute’s limited resources undermine its healthcare team’s desire to provide ideal screening, active surveillance, timely diagnosis, and treatment of this potentially curable disease. For example, the recommendations for MRI may not be feasible in all cases in Uganda. A rationalised alternative diagnostic and management approach that is as available to a man in Kashambya, Rukiga District as it is to a man in Kololo, Kampala needs to be developed.
This requires a mindset change among the rulers and other policy makers, to shift public spending from supporting the lifestyles of the political elite, to the health and other social welfare needs of most citizens. Priorities matter. One place to start is the acquisition and staffing of mobile screening clinics that target men with a higher risk of prostate cancer and other non-communicable diseases. These clinics should be conducted by clinical officers and nurses that have received thorough training and certification in this field of healthcare. Uganda does not have enough specialists and services to provide this care to its increasing population of males that may require screening, active surveillance, or treatment. This is an issue that needs very urgent attention, funding, and remedy.
Tingasiga, though all men are at risk of developing prostate cancer, it does not mean that we shall all get it. It means that we should pay attention, for we are not exempt from it. Happily, we can prevent it, and it is treatable. When caught early.
© Muniini K. Mulera